How to become a strategic purchaser of rehabilitation services

Abstract Rehabilitative care is often overlooked and underfunded despite being a key component of universal health coverage, and now faces further neglect due to indirect impacts of the coronavirus disease 2019 pandemic. Policy-makers can leverage strategic purchasing approaches to make the most of available funds and maximize health gains. To implement more strategic purchasing of rehabilitation, health planners must: (i) develop and prioritize evidence-based rehabilitation service packages; (ii) use fit-for-purpose contracting and provider payment mechanisms to incentivize quality and efficient service delivery; and (iii) strengthen stewardship. This paper examines these three policy priorities by analysing their associated processes, actors and resources based on country experiences. Policy-makers will likely face several obstacles in operationalizing these policy priorities, including: inadequate accountability and coordination among sectors; limited data and research; undefined and non-standardized rehabilitation services, costs and outcomes; and inadequate availability of rehabilitative care. To overcome challenges and institute optimal strategic purchasing practices for rehabilitation, we recommend that policy-makers strengthen health sector stewardship and establish a framework for multisectoral collaboration, invest in data and research and make use of available experience from high-income settings, while creating a body of evidence from low- and middle-income settings.


Introduction
One third of the world's population are living with health conditions that might benefit from rehabilitation services, which improve functioning and are fundamental to enhancing well-being and quality of life. 1,2 The coronavirus disease 2019 (COVID-19) pandemic has increased the gap 3 between the need for and availability of rehabilitation services. During the pandemic, more than half (62%, 101 of 163) of surveyed countries had experienced disruption of rehabilitation services, possibly as a result of resources being diverted towards COVID-19 care, 4,5 disruptions that jeopardized the quality of life and functioning of populations.
Adequate health financing is important in ensuring efficient, integrated and sustainable delivery of rehabilitation services. 6,7 Such financing mobilizes revenue for health services, including for rehabilitation, and makes the best use of resources by pooling these funds and being strategic about purchasing services on behalf of the population. 8 In this article, we discuss why strategic purchasing in resource-constrained settings can expand coverage of rehabilitation services, and introduce three related policy priorities. Adapting a framework that describes how countries drive health system improvement ( Fig. 1), 9 we outline the key processes, actors and resources that are needed to implement the three policy priorities.
This article is directed towards policy-makers in middleincome countries, and includes experiences from high-income countries.

Strategic purchasing
Strategic purchasing can improve service outcomes and promote integration of rehabilitation services into health systems. Purchasing refers to the transfer of funds from third-party payers to health-care providers to pay for services delivered to a covered population. 10 Strategic purchasing refers to deliberate efforts to link these payments with population health needs or service provider performance. Such purchasing uses policy instruments such as clearly defined benefits packages, contracting and provider payment mechanisms to maximize equitable and quality service outcomes from constrained resources. 11,12 For rehabilitation, strategic purchasing approaches consider: (i) What does the population need in relation to rehabilitation? Which health conditions can affect people's functioning and create the largest disability burden?; (ii) Which rehabilitation services are available at different levels of health care (i.e. primary, secondary, tertiary, specialized) and can be financed to effectively meet this need?; (iii) Which public and private providers can best deliver these services from specialized rehabilitation institutions, rehabilitation wards in facilities, individual rehabilitation providers or assistive technology providers, including pharmacies?; and (iv) How to standardize and set tariffs, payment models and quality measures for rehabilitation services, considering the diversity of need among individual users and the diversity of providers delivering rehabilitation care.
Through these considerations, strategic purchasing focuses resources on outcomes that expand financial protection and rehabilitation service coverage and help countries progress towards universal health coverage goals. 13 Strategic purchasing is technically intricate, capacity intensive and politically complex to implement. 14,15 The peculiarities of financing and delivery of rehabilitation services add layers of complexity. For example, there is a general lack of coordination and accountability across the various sectors financing, purchasing and delivering rehabilitation services; the data needed to drive strategic purchasing decisions are not available, of poor quality or insufficient to inform true service needs and track service outcomes; 16,17 and outcomes themselves are difficult to define and standardize in health care settings as they are measured by indicators of functionality and can vary according to the treatment goals and subjective experience of individual patients. 6,18,19 Significant gaps in rehabilitation service availability 20 and access can create additional hurdles for purchasers trying to link payment to quality or equity outcomes.

Policy & practice
How to purchase rehabilitation services Tamara Chikhradze et al.
Despite these complexities, rehabilitation purchasers can rely on several policy options and instruments to improve purchasing decisions. 21

Policy priorities
The transition from passive purchasing to strategic purchasing represents a change in thinking in how rehabilitation services are prioritized, paid for and delivered. We present three key policy priorities that can promote this shift and enable reforms to improve efficiency and quality of care: (i) developing and prioritizing evidence-based benefits packages for rehabilitation; (ii) using contracting and provider payment mechanisms to pay for quality and efficient rehabilitation services; and (iii) instituting and strengthening stewardship for purchasing rehabilitation services.
These policy priorities, their implementation components and country examples are based on consultations with health financing and rehabilitation experts and peer-to-peer exchanges with practitioners from over 40 countries. 17 The processes, actors and resources needed to implement the priorities are also informed by experiences of strategic health purchasing reforms in other health service areas.

Evidence-based benefits packages
A national health benefits package refers to the set of services that can be feasibly financed and provided within a country's context. 22 Strategic purchasers should explicitly define priority rehabilitation interventions to be included in a health benefits package and align them with population needs, service provision capacities and available resources. 23 Table 1 lists key processes, actors and resources that are integral to developing and prioritizing benefits packages for rehabilitation within existing health financing systems.
Rehabilitation service packages should be developed within the existing health service prioritization framework. Essential processes include estimating population need, comparing need to currently available services and potential solutions, estimating related costs, setting tariffs and matching the package with available financial resources. This approach will help avoid vague, non-transparent and underfunded benefits packages that are occasionally Ensuring Accountability

Ability to drive systems change
Notes: Institutional architecture for health systems strengthening refers to the processes, actors and resources that interact -or fail to interact -to create health system improvements. The architecture includes activities to generate, analyse and use evidence to formulate health systems strengthening solutions, manage their adoption and implement the change. The framework helps countries to self-assess essential capacities to perform key health systems strengthening functions, plan for building capacities and track improvements. For this article, we adapted this framework to map processes, actors and resources that are necessary to implement selected policies for strategic health purchasing and perform a combination of functions outlined in the framework. Policy-makers can use this mapping to understand the stakeholder landscape and resource requirements of strategic purchasing initiatives. observed in publicly funded systems in low-and middle-income countries. 22 For example, the Explicit Health Guarantees package 24 of Chile covers rehabilitation services in response to the 2016-2017 National Health Survey, which estimated that 42% of the Chilean population had moderately or severely reduced functioning that might benefit from rehabilitation. 25 According to the country's existing prioritization framework, inclusion in this list depends on the severity and frequency of the health condition the service addresses, the intervention's effectiveness, service delivery capacities and available funding. Selected rehabilitation services satisfied all these criteria before inclusion in the package. 25 Rehabilitation benefits should be selected by multistakeholder committees or working groups, and based on prioritization frameworks. Because of the close linkage of rehabilitation to the rights of people living with disabilities, civil society actors such as organizations of people with disabilities can play a fundamental role in ensuring user responsiveness of benefits and advocating to prioritize rehabilitation in financing schemes. In the Philippines, such organizations helped facilitate the prioritization and the inclusion of select mobility, prosthetic, orthotic and rehabilitation services in the Z Benefits package under the national health insurance scheme, 26 making the Philippines one of the exemplary countries to explicitly spell out the type and volume of rehabilitation services provided through a financing scheme. 17 Data and evidence are essential resources for the formulation of benefits packages. Rehabilitation need is frequently informed by disability data, or prevalence of health conditions that can cause permanent or temporary functional difficulties. Looking beyond disability data is important in capturing rehabilitation needs of individuals without a disability status or with cognitive functional challenges that may not be adequately captured by self-reported surveys. 27 Health technology assessment can help prioritize cost-effective services with the highest return on investment. Such assessments for rehabilitation services are scarce in middle-income countries, and when such country-level evidence is not available, policy-makers can refer to global guidance on rehabilitation needs estimation and cost-effectiveness of rehabilitation interventions. 28 Data and research on rehabilitation service availability, readiness, costs and budget impact can inform what might be realistically planned and provided, and should ultimately drive prioritization processes. This approach promotes budget accountability and transparency, and helps ensure that user, provider and purchaser expectations are aligned. 12

Provider payment mechanisms
Contracts are negotiated agreements between purchasers and providers. Provider payment mechanisms can be part of contracts and define how funds are transferred to providers. These mechanisms are key tools for a strategic purchaser to promote the efficiency and quality of rehabilitation services. 29 Table 2 highlights the main processes, actors and resources needed to develop contracts and implement provider payment mechanisms for rehabilitation services.
When contracting for health services, purchasers should develop legal frameworks for collaboration, identify public and private rehabilitation providers to contract, construct an agreement about what will be purchased, determine how it will be purchased, set minimum required standards for facilities and expected outcomes, and develop systems to continuously monitor provider performance. 29 The format of the agreement can vary between and within countries, and not all rehabilitation contracts will cover these components. For example, Rwanda has recently adopted accreditation standards for rehabilitation ser-vices, which are used to qualify a facility to receive funds from public purchasers and establish a non-competitive contract with them. Contracting with private rehabilitation facilities in Rwanda is more structured and competitive, and depends on the agreements set with public funders, social insurers and private insurers. 30 The purchaser of Pakistan's Sehat Sahulat Program for people with disabilities competitively contracts a facility based on eligibility criteria. 31 The contract mandates the provision of a select set of services free of charge to programme beneficiaries and retroactively reimburses based on submitted bills.
One common observation in lowand middle-income countries is that rehabilitation contracts often lack specifications on the expected outcomes of care. 17 Strategic purchasing shifts the focus of investment from service inputs or outputs (e.g. physiotherapist salary or number of physiotherapy visits), towards service outcomes. This practice is novel to many low-and middle-income countries, whereas high-income countries with advanced financing systems for rehabilitation use measures such as improvements in functioning, autonomous living, discharge to community, return to the workforce, quality of life, reduced depression and patient satisfaction to track rehabilitation service outcomes. [32][33][34] Countries can adopt and adapt these measures for their own strategic purchasing objectives; they can also harness tools and resources from high-income settings that can help classify and systematize coding of rehabilitation data to inform payment models and service outcomes. 35,36 Implementing contracts and provider payment mechanisms can be resource intensive as they rely heavily on well-defined outcomes of care, information systems and data, as well as the capacity to report and monitor. Purchasers must find a sustainable balance between overly standardized, inflexible and passive payment practices that do not consider service outcomes -such as the voucher system for Georgia's State Programme for Social Rehabilitation and Childcare 37 -and overly complicated payment mechanisms with bespoke reporting requirements and fragmented reporting, such as the United States' Medicare and Medicaid programmes. 38 Countries with advanced strategic purchasing approaches are more efficient in tailoring payment mechanisms to different settings where rehabilitation services are provided -outpatient and inpatient -and variability in the expected outcomes of care. For example, Swiss insurance and some Canadian workers' compensation schemes pay for each outpatient rehabilitation service with a pre-defined cap on the number of visits per treatment cycle. 18,19 The cap can be adjusted based on individual patient needs by a referring clinician or an insurer (a gatekeeper). Inpatient rehabilitation is paid for by an activitybased mechanism or Diagnosis Related Groups by Australian Medicare and Medicare in the United States, respectively. 38,39 Both mechanisms consider variations in condition, resource needs and required length of care at different levels of functional loss.
The scarce evidence on the effectiveness of different contracting and provider payment mechanisms for rehabilitation is limited to high-income settings and remains unexplored for low-and middle-income settings. Therefore, piloting and testing innovative approaches, conducting implementation research and other adaptive learning methods is needed to better understand the feasibility and impact of different contracting approaches and provider payment mechanisms on rehabilitation outcomes. Countries can learn from their own and peer experiences on different purchasing approaches for rehabilitation and the global health community should actively invest in this exchange.

Stewardship for purchasing
Effective stewardship for strategic purchasing requires leadership to develop policies, set clear objectives, align various actors to achieve those objectives, and enforce the regulatory environment for purchasing arrangements. 12,21,40 See Table 3 for implementation components of this policy priority.
One effective strategy is to identify and empower rehabilitation focal points within health ministries to champion health sector stewardship for rehabilitation, including purchasing policies. Rehabilitation services are purchased from health and non-health sectors. The latter include disability-focused programmes in the social, labour, defence or education sectors, or insurance schemes that manage disability, accident and/or workers' compensation schemes. 41 Further, national and subnational governments may be responsible for programming and purchasing different levels of rehabilitation care, requiring intragovernmental coordination and collaboration. Thus, health sector stewards of rehabilitation services need to set up or strengthen multisectoral and multistakeholder coordination platforms, develop policies and frameworks that clearly define roles and responsibilities of different purchasing institutions and align their objectives towards common population-level goals.
For example, the Rehabilitation Services Unit of the Kenya Ministry of Health leads the multistakeholder Rehabilitative and Assistive Technology Interagency Coordinating Committee and oversees the rehabilitation technical working group, which shapes county rehabilitation agendas and advises county directors for health on rehabilitation financing reforms -including for strategic purchasing. These reforms are coordinated at the county level with stakeholders from the health and non-health sectors. Reforms are guided by the National Rehabilitation and Assistive Technology Strategy and other national policies. 42 Similarly, in Brazil, municipal governments are responsible for primary health care under the country's highly decentralized Unified Health System. As part of implementing the national policy on family health support centres, they have benefited from financial support and policy direction from the national health ministry (from 2008 to 2016) to increasingly integrate rehabilitation into primary health care and successfully expand the number of qualified rehabilitation professionals (e.g. physiotherapists, speech therapists, psychologists and occupational therapists) offering services to those experiencing functional difficulties. 43 Numerous legal, operational and technical resources can support stewardship of rehabilitation purchasing. These resources include strategic or operational plans, terms of reference for coordination platforms, and legal or policy documents that clarify the roles of various institutions, empower health sector actors to be effective stewards for rehabilitation and enable purchasers to be strategic in their investments.
Global momentum created by the Rehabilitation 2030 agenda 44 provides an opportunity to promote health ministry stewardship. Rehabilitation in Health Systems: Guide for Action 45 offers tools and platforms for situation assessment, strategic planning and stakeholder engagement. 46 Health ministry leaders in El Salvador, Georgia and Jordan, among others, have effectively used these resources to convene stakeholders, establish a mutual understanding of the pressing challenges, and collaboratively identify pathways towards strengthening rehabilitation in health systems. These processes can also help facilitate discourses on strategic purchasing.

The way forward
Strategic purchasing is a powerful but technically demanding approach to promoting quality and equity of services in resource-constrained settings. We propose following certain first-order priorities for policy-makers and managers committed to improving purchasing decisions for rehabilitation.
Purchasers need data to make strategic decisions, so an immediate priority should be identification and investment in data that can inform benefits, con-tracts, provider payment mechanisms and accountability mechanisms. While countries build capacities and cultures of data production, transparency and exchange among rehabilitation providers and multisectoral purchasers, they can adapt global resources and information to their local and/or national context.
Strategic purchasing decisions for rehabilitation should be inclusive and multisectoral. Rehabilitation is purchased and provided by multiple sectors. Without clarity on roles and accountability frameworks, everyone and no one is simultaneously accountable. In line with global momentum to strengthen rehabilitation care through a health system lens, 47 the health sector should take on the stewardship role, collaborating and coordinating with other sectors to align purchasing efforts with achieving population-level goals.
Technical and academic stakeholders within the global health community have a key role to play in facilitating learning about and informing strategic health purchasing policies for rehabilitation. There is still a lot to learn about the feasibility and effectiveness of strategic purchasing instruments such as benefits packages, contracts and provider payment mechanisms for rehabilitation in resource-constrained settings and emerging health systems. The global health community should focus on innovating on, piloting, testing and studying these approaches to fill the knowledge gap and enrich the global evidence base with experiences from low-and middle-income countries. Over time, this experience will inform global normative instruments and resources for countries to use across different regions, resource settings and health systems contexts.

Conclusion
The need to reinforce strategic use of funds for rehabilitation is urgent -especially in resource-constrained settings and considering post-COVID-19 realities. We present policy priorities that can help health system leaders make strategic purchasing decisions and target investments in ways that accelerate progress towards universal health coverage. We also encourage the global health community to invest in applied research on purchasing rehabilitation services, so policy-makers can assess innovative approaches and leverage high quality evidence throughout this journey. 

Enfoques estratégicos para la adquisición de servicios de rehabilitación
La atención de rehabilitación suele pasar desapercibida y carecer de fondos a pesar de ser un componente clave de la cobertura sanitaria universal, y ahora se enfrenta a una mayor desatención debido a las repercusiones indirectas de la pandemia de la enfermedad por coronavirus de 2019. Los responsables de formular las políticas pueden aprovechar los enfoques de adquisición estratégica para sacar el máximo provecho de los fondos disponibles y maximizar los beneficios para la salud. Para aplicar una adquisición más estratégica en materia de How to purchase rehabilitation services Tamara Chikhradze et al.